Tricuspid Valve Insufficiency – ABC CARDIOL

ABCIC

Review Article

My Approach to a Standardized Assessment of the Tricuspid Valve: A Contemporary Analysis

Halsted Alarcão Gomes Pereira da Silva et al. Alexandre Costa Souza Adenalva Beck

Abstract

Tricuspid regurgitation (TR) remains one of the most frequent valvular diseases encountered in echocardiographic practice. Mild cases generally do not require further investigation or specific treatment. Moderate and severe valvular disease, however, require more detailed anatomical and etiological assessment to better understand the underlying pathophysiological mechanism.

Two-dimensional echocardiographic analysis is the initial examination of choice and should be performed in a standardized manner, with individual identification of the leaflets using the main transthoracic echocardiographic windows. The description of complementary parameters – such as right ventricular (RV) systolic function, myocardial deformation assessed by longitudinal strain, right-sided chamber diameters and volumes, and estimation of pulmonary pressures – guides the clinician regarding potential therapeutic strategies and provides relevant prognostic information.

In this context, the 2025 European Society of Cardiology (ESC) guideline reinforces the importance of a standardized and comprehensive evaluation of the tricuspid valve and its hemodynamic repercussions. Most of this assessment can be performed using widely available two-dimensional transthoracic echocardiography.

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ABC

Original Article

Artificial Intelligence–Driven Detection, Characterization, and Risk Stratification in Patients with Severe Tricuspid Regurgitation

Luna Varela do Carmo et al. Auristela Isabel de Oliveira Ramos Dorival Julio Della Togna Eduardo da Silva Farias Dimytri Alexandre de Alvim Siqueira

Abstract

Background:

Tricuspid regurgitation (TR) is prevalent and challenging to manage. There is a high mortality rate associated with isolated surgery and late referral for intervention. Additionally, there has been a recent expansion of transcatheter therapies. In Brazil, there is a lack of data and validation of prognostic tools.

Objective:

To investigate and define clinical, laboratory, and echocardiographic data from patients with severe TR based on variables collected through the training of an artificial intelligence (AI) model.

Methods:

This observational, single-center, non-interventional, retrospective study was based on 71,911 echocardiographic reports performed between 2021 and 2024. A natural language processing (NLP) model was developed in Python to identify cases of severe TR, extract variables, and perform automated calculation of the TRI-SCORE and EuroSCORE II, which were subsequently reviewed. A two-tailed p-value < 0.05 was considered statistically significant.

Results:

A total of 803 patients with severe TR were identified. The mean age was 68.8 ± 13.5 years, and 64.1% were female. Hypertension (71.7%) and atrial fibrillation (69.4%) were the most prevalent comorbidities. Secondary etiology predominated (96.8%), mainly associated with mitral valve disease (68.5%). Surgical risk was high (medians: EuroSCORE II = 13.4%; TRI-SCORE = 7). Mortality was 17.1%. In the secondary mortality analysis, multivariable regression identified independent predictors, such as high-risk TRI-SCORE (relative risk [RR] 2.19; 95% CI 1.14-4.21) and increased creatinine (RR 3.13; 95% CI 1.91-5.14).

Conclusions:

In the largest Brazilian cohort of severe TR, constructed with the aid of AI, the disease demonstrated high clinical and prognostic complexity. The application of NLP to large echocardiographic databases proved to be efficient and may support multicenter studies.

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ABCIC

Review Article

Tricuspid Valve: Anatomical Basis and Patient Selection Criteria for Transcatheter Structural Interventions

Alexandre Costa Souza et al. Halsted Alarcão Gomes Pereira da Silva Alex dos Santos Felix

Abstract

Tricuspid regurgitation has been recognized as a relevant clinical entity, with a direct impact on morbidity and mortality. Recent advances in multimodal cardiovascular imaging have promoted more detailed anatomical and functional assessment of the tricuspid apparatus, guiding the indication and planning of transcatheter interventions. To provide a review of the anatomical basis of the tricuspid valve and discuss echocardiographic and clinical criteria for selecting candidates for transcatheter therapies. This narrative review of the anatomical variability of the tricuspid valve and its subvalvular apparatus incorporates recent recommendations from echocardiography societies and clinical evidence. Special emphasis has been given to three-dimensional echocardiography, transesophageal echocardiography, and computed tomography for morphological and functional characterization of tricuspid regurgitation. Contemporary evidence has demonstrated that up to 45% of patients present with non-classical morphologies (quadricuspid or pentacuspid valves), which impact the viability and outcomes of edge-to-edge repair. The integration of three-dimensional echocardiography enhances accuracy in grading regurgitation severity, enables precise measurement of the vena contracta area, and assists in device selection. Clinical factors including right ventricular function, pulmonary artery systolic pressure, and the presence of intracardiac devices also influence patient selection. Appropriate selection of candidates for transcatheter tricuspid valve therapies requires a systematic approach with integrated application of imaging methods and clinical parameters. Detailed echocardiographic characterization of leaflet morphology, coaptation gap, and annulus geometry is crucial for planning the procedure, selecting the device, and predicting outcomes.

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IJCS

Case Report

Transcatheter Bicaval Valve System in the Treatment of Torrential Tricuspid Regurgitation and Refractory Systemic Hypervolemia: 12-Month Outcome

Rômulo Francisco de Almeida Torres et al. Alessandro Kraemer Rafael de Almeida Torres Fernanda Proença Lepca Bozzi … Sarah Fagundes Grobe Eduardo Mendel Balbi Filho Guilherme Barreto Gameiro Silva

Abstract

Severe isolated tricuspid regurgitation (TR) is associated with limiting symptoms, negative impact on quality of life, and poor prognosis. The TricValve^® device is a transcatheter self-expanding biological valve system designed to mitigate systemic volume overload, improve quality of life, and improve congestive symptoms. We report a 12-month follow-up of a 61-year-old woman with signs of refractory systemic hypervolemia and torrential TR who underwent the procedure. The treatment resulted in significant weight loss, improvement in signs of hypervolemia, and improvement in functional class (FC).

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ABCIC

Original Article

First Percutaneous Orthotopic Tricuspid Valve Implantations using the LuX-Valve Plus Device in Latin America: Report of the First Three Cases

Fernanda Esteves et al. Vinícius Esteves Marcio Mendes Pereira Frederico José Neves Mancuso … Marden Tebet Sergio Kreimer Edmur Carlos de Araújo Francisco Monteiro de Almeida Magalhães

Abstract

Background:

Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality, especially in patients with contraindications for surgery. Transcatheter tricuspid valve replacement has emerged as a minimally invasive alternative for this population, with the LuX-Valve Plus device designed for orthotopic implantation via the transjugular route.

Objective:

To report the first 3 cases of transcatheter tricuspid valve replacement using the LuX-Valve Plus device in Latin America, assessing the feasibility, safety, and immediate clinical outcomes.

Methods:

The study included 3 female patients with torrential TR and high surgical risk. Pre-procedure assessment included transesophageal echocardiography, 3-dimensional transthoracic echocardiography (3D TEE), computed tomography, and cardiac catheterization. The procedure was performed via transjugular access, under general anesthesia, with 3D TEE and fluoroscopy guidance. Implant efficacy was assessed as resolution of TR, transprosthetic gradient, and post-procedure complications.

Results:

The implants were successful in all cases, with complete resolution of TR, absence of paravalvular leaks, and adequate transprosthetic gradient. Right ventricular function was preserved, and all patients were discharged 3 to 4 days after the procedure with no significant complications.

Conclusion:

Transcatheter tricuspid valve replacement using the LuX-Valve Plus was shown to be a viable and safe alternative for patients with severe TR and high surgical risk. The use of 3D TEE was essential to the planning and execution of the implant. Further studies are needed to assess durability and long-term clinical outcomes.

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ABCIC

Review Article

Advances in Percutaneous Tricuspid Valve Treatment

Marcio Mendes Pereira et al. Maria Estefânia Otto Fernando Melo Netto Fernanda Esteves

Abstract

Tricuspid regurgitation (TR) is a frequently underdiagnosed and undertreated condition, often associated with poor clinical outcomes, particularly in elderly and high-risk surgical patients. As the prevalence of TR continues to rise and traditional surgical methods face limitations, percutaneous techniques have emerged as promising alternatives. This article reviews the latest advancements in the percutaneous treatment of TR, highlighting new etiological and quantitative classifications, in addition to exploring the indications and outcomes of key techniques, including percutaneous edge-to-edge repair and transcatheter valve replacement. Moreover, it discusses the anatomical challenges involved and the vital role of echocardiography in periprocedural planning and monitoring. Based on current data, percutaneous interventions have shown effectiveness in alleviating symptoms and enhancing the quality of life for patients with severe TR, making them a viable option for those who are not candidates for conventional surgery.

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ABC

Research Letter

First Performance of Transjugular Transcatheter Tricuspid Valve Replacement with the Lux-Valve Plus System in Latin America. A Case Report

Vinicius Esteves et al. Pedro Beraldo de Andrade Sergio Kreimer Fernanda Almeida Esteves … Francisco Monteiro de Almeida Magalhães Thomas Modine

Introduction

The prevalence of tricuspid regurgitation (TR) increases with age, concomitant left-side heart disease, and chronic atrial fibrillation. Moderate or severe TR is associated with excess mortality and poor outcomes. The interventional treatment of choice is tricuspid valve repair, with a prosthetic ring capable of reducing the tricuspid annulus diameter, improving valve leaflet coaptation, and correcting regurgitation. Valve replacement is reserved for patients who do not have anatomical conditions for repair. However, an isolated surgical approach to the tricuspid valve continues to be rarely indicated, and there are still no data showing improved survival with TR surgical treatment alone, making this condition undertreated in clinical practice, despite the increased mortality rate in patients with moderate to severe TR clinically-only managed.

Based on these observations, the treatment of TR has recently been shifting from a conservative to a more interventional approach. This shift has led to first-in-human attempts at transcatheter tricuspid valve interventions (TTVI). Several devices have been developed, with strategies based on reducing the valve annulus, improving coaptation between the leaflets, or valve replacement. In a propensity-matched case-control study, TTVI was associated with 40% greater survival and freedom from heart failure rehospitalization.

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ABC

Case Report

Left Atrial Appendage Occlusion and Implantation of a Bicaval System: Report of a Simultaneous Transcatheter Procedure in a Critically Ill Elderly Patient

Marcos Cherem et al. Carlos Eduardo Bernini Jamil Abdalla Saad Dirceu Barbosa Dias Sobrinho … Marcio Sérgio Carvalho Silva Ruthnea Aparecida Lazaro Muzzi

Case Report

We report the case of an 87-year-old male patient who presented with severe torrential tricuspid regurgitation with important hemodynamic repercussions and conditions of right heart failure, episodes of pulmonary thromboembolism, and deep vein thrombosis in the lower limbs, in follow-up at the hospital’s cardiology service since 1996.

The patient had severe comorbidities, including permanent atrial fibrillation in use of prophylactic enoxaparin and impossibility of safe oral anticoagulation due to chronic renal failure. Furthermore, he concomitantly presented stage 3 essential hypertension, left ventricular hypertrophy, hypercholesterolemia, and venous insufficiency of the lower limbs. Although he was using methyldopa, amiodarone, bisoprolol, enoxaparin, epoetin, dapagliflozin, furosemide, spironolactone, propatylnitrate, atorvastatin, and allopurinol, he progressively developed severe tricuspid insufficiency, right heart chamber dilation, and congestion in the venae cavae and right atrium, which were refractory to optimized clinical treatment, with progressive worsening of renal function. The transthoracic echocardiogram revealed severe and maladaptive concentric hypertrophy of the left ventricle, with systolic involvement of the right ventricle, important tricuspid insufficiency, important biatrial enlargement, and moderate pulmonary hypertension.

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ABC

Original Article

Tricuspid Regurgitation and Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Bruna Olandoski Erbano et al. Nicolle Amboni Schio Renato Delascio Lopes Tiago Costa Bignoto … Marcia Olandoski Raquel Silva Brito da Luz Guilherme Dagostin de Carvalho Lucas Henrique Olandoski Erbano Auristela Isabel de Oliveira Ramos Fausto Feres José Rocha Faria Neto Cristina Pellegrino Baena Dimytri Alexandre de Alvim Siqueira

Abstract

Background

The extent of cardiac damage associated with aortic stenosis has important prognostic implications after transcatheter aortic valve replacement (TAVR). However, the role of tricuspid regurgitation (TR) in this clinical setting is still unclear.

Objectives

To explore the association between TR and mortality in patients undergoing TAVR and assess changes in TR severity post TAVR and its relationship with short and mid-term mortality.

Methods

Relevant databases were searched for articles published from inception until August 2020. Out of 414 screened studies, we selected 24 that reported the degree of TR pre or post TAVR. The primary outcome was all-cause mortality, and random effects meta-analysis models were conducted (at a significance level of 5%).

Results

Seventeen studies reported associations between pre-TAVR TR and all-cause mortality (> 45,000 participants) and thirteen accessed TR severity post TAVR (709 participants). Moderate/severe baseline TR was associated to higher all-cause mortality both at 30 days (HR 1.65; 95% CI, 1.20-2.29) and 1.2 years (HR 1.56; 95% CI, 1.31-1.84). After TAVR, 43% of patients presented a decrease of at least one grade in TR (30 days, 95% CI, 30-56%), sustained at 12.5 months in 44% of participants (95% CI, 35-52%). Persistence of significant TR was associated with a two-fold increase in all-cause mortality (HR 2.12; 95% CI, 1.53-2.92).

Conclusions

Significant TR pre TAVR is associated with higher mortality. Although TR severity may improve, the persistence of significant TR post TAVR is strongly associated with increased mortality. Our findings highlight the importance of a detailed assessment of TR pre and post TAVR and might help identify patients who may benefit from more careful surveillance in this scenario.

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ABCIC

Review Article

My Approach to Three-Dimensional Echocardiography for Pathophysiological Classification of Tricuspid Regurgitation

Alex dos Santos Felix et al. Monica Luiza de Alcantara Konstantinos Papadopoulos

Introduction

Although it was known as the “forgotten valve” in the past, there has been increasing interest in studying the tricuspid valve (TV) during the last two decades. Tricuspid regurgitation (TR) has been identified as a prognostic marker not only when associated with other cardiac diseases, like heart failure, mitral regurgitation, or aortic stenosis,^– but also as an isolated entity. Understanding the pathophysiological mechanisms of this disease is of paramount importance, since new options of transcatheter devices and techniques are emerging, offering invasive treatment for high-risk patients unsuitable for surgical intervention.

The TV is difficult to image in transesophageal echocardiography (TEE) for the following reasons: 1) the leaflets are much thinner compared to mitral leaflets, with greater anatomic variability; 2) it is an anterior structure, far away from the esophagus, with acoustic shadowing from the fibrous heart skeleton; and 3) it cannot be aligned to the esophageal probe in order to acquire en face views and requires use of lateral resolution. These restrictions may limit the ability of traditional TEE to evaluate the TV, making it necessary to complement the evaluation with special windows from the lower esophagus and transgastric views. Different from other cardiac valves, images of the TV obtained from transthoracic echocardiography (TTE) usually have better resolution than images obtained by TEE. Even though all protocols start with two-dimensional (2D) assessment of the TV, three-dimensional echocardiography (3DE) plays an important role in the evaluation of TV diseases, due not only to its ability to precisely depict the anatomy of the valve and the subvalvular apparatus, but also to its accuracy in quantitation of right ventricular (RV) and right atrial volumes and function and functional analysis of valvular dysfunction, especially for grading TR and evaluating dynamics of the tricuspid annulus (TA) through dedicated software. All of this information is of unparalleled importance for patient management and pre-procedural planning in surgical and transcatheter approaches.

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ABCIC

Editorial

A Clinician’s View of Tricuspid Regurgitation: What do I Need to Know? When to Intervene?

Tricuspid valve dysfunction was considered a benign clinical situation for a long time, but with the advancement of diagnostic imaging methods and better clinical stratification of patients with structural heart disease, adequate classification of tricuspid regurgitation has become fundamental to decision making in the context of a Heart Team.

The first assessment to be taken into account is the etiology of the dysfunction. With a low prevalence, the primary etiology, mainly due to rheumatic and congenital causes, has a well-established intervention flowchart, primarily based on the presence of symptoms or hemodynamic repercussions on the right side of the heart.

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ABC

Research Letter

Emerging Topics in Heart Failure: Interventional Heart Failure Therapies

João Manoel Rossi Neto et al. Dirceu Rodrigues de Almeida Fernando Antibas Atik Monica Samuel Avila Marcely Gimenes Bonatto

Treatment of Secondary Mitral Regurgitation

Before considering percutaneous treatment of mitral regurgitation (MR) for patients with heart failure (HF) with reduced ejection fraction (HFrEF) and severe MR, we recommend that guideline-directed medical therapy be optimized, including cardiac resynchronization therapy and revascularization, where appropriate.

The use of the edge-to-edge device could benefit patients with moderately severe or severe secondary MR (effective regurgitant orifice area [EROA] ≥ 30 mm² and/or regurgitant volume > 45 mL) with a left ventricular ejection fraction (LVEF) of 20 to 50%, left ventricular (LV) end-systolic diameter < 7.0 cm, and persistent symptoms despite maximized evidence-based medical therapy, with the participation of an experienced multidisciplinary team in the evaluation and treatment of HF and MR.

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IJCS

Original Article

Early Outcomes of Modified De Vega Annuloplasty for Functional Tricuspid Regurgitation at a Brazilian Hospital

Diogo Luiz de Magalhães Ferraz et al. Karina Mascarenhas Bezerra Alves Larissa Almeida Barp Santos Girliney dos Santos Leandro … Cristiano Berardo Carneiro da Cunha Rodrigo Mezzalira Tchaick Igor Correia Silva João Paulo Segundo de Paiva Oliveira Jeú Delmondes de Carvalho Júnior Felipe Ribeiro Walter Stephanie Steremberg Pires D'Azevedo Tais Lins Severo da Silva Verônica Soares Monteiro Fernando Augusto Marinho dos Santos Figueira

Abstract

Background:

Right valve diseases are not benign, the tricuspid regurgitation has a significant impact on morbidity and mortality of patients.

Objectives:

This study aimed to report the short-term results of tricuspid annuloplasty using the De Vega technique modified by Manuel Antunes.

Methods:

A descriptive-analytical study was performed to evaluate the results of the tricuspid valvuloplasty performed at the Instituto de Medicina Integral Professor Fernando Figueira between 2012 and 2017. Data were collected by reviewing charts and databases of the Department of Cardiology and Cardiovascular Surgery of the institution. Those with rheumatic diseases or infective endocarditis with tricuspid valve involvement, or reoperation of the tricuspid valve were excluded. Student’s t-test and McNemar’s were used for statistical analysis. A p-value < 0.05 was considered statistically significant.

Results:

A total of 87 patients were studied, most of them were women (56.3%). The most associated heart valve diseases were mitral regurgitation (27.6%) and aortic regurgitation (20.7%). There was a significant decrease in the degree of tricuspid regurgitation in the postoperative period, with 83.3% of patients with none or mild regurgitation and only 1.1% with severe regurgitation (p = 0.0077).

Conclusions:

In the current study, tricuspid valve annuloplasty using the modified De Vega technique was shown to be effective in the short term. Further studies are needed to evaluate the long-term results.

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ABC

Case Report

Contusio Cordis Associated with Atrioventricular Block and Tricuspid Regurgitation

Giulio Cesare Longo Neto et al. Wolney de Andrade Martins Humberto Villacorta Junior Eduardo Nani da Silva … Paula Maira Alves Haffner Davyson Gerardt de Souza

Introduction

The expression “contusio cordis” defines a lesion of the cardiac myocyte, hemorrhagic or fibrotic, due to the application of violent kinetic force resulting from a blunt trauma to the precordial region. Syncope is almost always the first clinical manifestation observed, and commonly precedes death. Contusio cordis differs from commotio cordis, the latter representing a cardiac electromechanical disorder consequent to a blunt trauma to the precordial region, at a critical moment of the cardiac cycle, which occurs within 10 to 30 ms from the T-wave peak, a period susceptible to the development of ventricular fibrillation ^– . Both forms are fatal most of the time ^, ^, ^– . Commotio cordis is a form of ventricular fibrillation, rather than a lesion in cardiomyocytes or adjacent organs ^, . It is a rare condition, leading most cases to death , and being more prevalent among men, because of its relationship to high-impact sports ^, . The accurate incidence of both entities is unknown, because there is no systematic way to register all cases; however, although rare in the literature, they are believed to be more common than reported ^, . Contusio cordis associated with complete atrioventricular block (CAVB) is an even rarer condition, with few cases reported. The objective of the present study is to report a case of contusio cordis associated with CAVB and tricuspid regurgitation (TR).

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ABC

Case Report

Tricuspid valve lesion due to penetrating chest trauma

Renata de Carvalho Bicalho Carneiro et al. Fernanda de Azevedo Figueiredo Luciana Campomizzi Calazans Marcelo Martins Pinto Filho … Daniel Furtado Vidigal Maria do Carmo Pereira Nunes

Tricuspid valve lesions caused by penetrating chest trauma are rare and often underdiagnosed. The objective of this report is to describe a case of severe tricuspid insufficiency secondary to a knifing incident with an insidious evolution, diagnosed 19 years after the incident. The case emphasizes the importance of adequate follow-up of patients that are victims of penetrating chest trauma for a long period after the injury, to detect possible late complications of the trauma.

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ABC

Case Report

Atypical presentation of rheumatic carditis in pregnancy

Lurildo Cleano Ribeiro Saraiva et al. Aluísio Macedo Ana Elizabeth M. Batista

We report the case of a 31-year old woman presenting with atypical rheumatic disease in the 28th week of the second pregnancy. Questions related to prevention of the disease and its treatment during the pregnancy-puerperium cycle are discussed.

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Correlação Clínico-Radiográfica

Case 1/2009: 21-month-old infant with partial atrioventricular septal defect, consisting of atrial septal defect and tricuspid insufficiency

CLINICORADIOLOGICAL SESSION

Case 1/2009 – 21-month-old infant with partial atrioventricular septal defect, consisting of atrial septal defect and tricuspid insufficiency

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ABC

Case Report

Corrected transposition of the great arteries: late clinical presentation, in the fifth decade of life

Roger Pereira de Oliveira et al. Panayotis Agorianitis Ronaldo Vegni Gustavo Nobre … Marcelo Kalichsztein José Kezen

The corrected transposition of the great arteries, rare congenital cardiopathy, is related to the largest incidence of cardiological complications. We report a case in which the clinical presentation of the disease occurred in the fifth decade of life, with tricuspid insufficiency, occasion that the patient was submitted to valvar replacement.

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